Rob Frediani: What do we know about the ACA?

Aug 31, 2016 | Leadership

Rob Frediani

Rob Frediani, VP of Operations and Mission Advancement

There has been a tremendous about of “ballyhoo” (def: “extravagant publicity or fuss”) about the Affordable Care Act (ACA). Here are some facts: it is currently a law, and hospitals, insurance companies, and states have spent a tremendous amount of time and money trying to adapt their daily businesses to adapt to the its requirements. I believe for the foreseeable future the ACA will continue to be a part of our personal and professional lives regardless of what happens in the presidential election later this year. So, I thought I would give a few “takeaways” that may be useful to prepare for the discussions that will undoubtedly occur in the future about the ACA.

Facts about ACA:
• The main goal of the ACA was/is to increase access to health care services and make it more affordable to the individual consumer, mainly for people who were previously uninsured.
• All US citizens and legal residents are required to have health insurance or pay a fine.
• There are two main strategies employed to achieve the goal of all citizens and legal residents having insurance.  These are (a) expanding Medicaid so that all states manage their own Medicaid programs, or (b) the purchase of subsidized private health insurance plans through government run exchanges.
• Insurance companies are required to include coverage for a variety of health care services deemed necessary by the government.
• The ACA prescribes levels of money in the bank to cover potential losses and ways to limit the amount of money a health insurance company can make from premiums, as well as setting limits on how much they can spend on marketing, administration, and profits.

A few things we have learned since ACA’s introduction:
• Coverage for uninsured populations has improved; however the ACA has so far failed to achieve universal coverage. There have been challenges achieving coverage for large segments of the population.
• The ACA has begun to refocus health care service providers from just treating diseases to preventing diseases and working to improve health outcomes.
• Hospitals that historically have taken care of the uninsured are benefiting from ACA because they are getting at least some level of payment for services provided to people who had no coverage previously.
• Employers that provide health insurance for their employees have continued to see increases in the cost of health benefits for their employees. Some speculate that the rate of increase will slow down once the “market has balanced.”

What this could mean for you:
• The ACA has spurred the continued development and use of managed care tools; remember HMOs, PPOs, etc.?
• In the future, more affordable health plans may emerge with the help of the federal government.
• Most health benefit programs or employer supplied health insurance benefits are adopting more and more managed care type rules.

What this means for Milwaukee Catholic Home:
• The state of Wisconsin is a limited participant in all ACA related activities, so we will see changes come a little slower to our market….but not much.
• If a resident of our Nursing Home wants to move or needs to move and that resident is covered in an ACA governed plan, a 60 day written notice is required to all who are involved: government, nursing homes, family, etc.
• MCH has improved and continues to improve our Ethics and Compliance programs.

The ACA is based on the view that health care is a right of United States citizenship. Not all Americans agree with this view, which is part of the reason why the nation is deeply divided over the ACA. The ACA was achieved through a tremendous amount of compromise within the hospital industry, insurance companies and the pharmaceutical industry, and because of that it is uniquely imperfect. While it is not always comfortable working within the new rules and regulations related to the ACA, it is a fascinating time to be in the health service provision industry. Many other countries adopted the “health care is a right” view hundreds of years ago and have had a lot of time to work the bugs out. Here in the United States, it is clear that we have just gotten started.